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Sandra sat and glanced over at Misha, hoping he would leave, but he didn’t. He was content to just stand there with a kind of smirk on his face, as if he expected some favor from her for having accompanied her into Fyodor’s office. As pushy as he was, she was glad she had not run into him alone upstairs.

“I have another question,” Sandra said, directing her attention to Fyodor.

“We are at your service, Doctor,” Fyodor said. As far as Sandra was concerned, even he exuded a suggestion of insincerity that made her uncomfortable.

“There was a very unfortunate anesthesia incident yesterday . . . ,” Sandra began, but then hesitated. She felt she needed to give some background, although Rhodes’s orders about not talking about the case made her reluctant to say very much. Yet she was talking to the people responsible for the performance of the anesthesia machine she had used, and she needed to be reassured.

As if sensing her quandary, Fyodor said, “We have heard about the event from Dr. Rhodes. First, we want to reassure you that the machine you were using had been serviced appropriately and in a timely manner. All its paperwork was in order. And as soon as we heard about the event, and following Dr. Rhodes’s orders, we brought the machine back here to our service center. We went over it extensively. I can assure you that it checked out perfectly, and it is back in service. There was no problem with the machine or its monitors, and Dr. Rhodes has been informed of this.”

Sandra nodded. Fyodor’s little spiel was more than she had expected. She didn’t know that Rhodes had asked to have the machine checked by Clinical Engineering, but it made sense. Perhaps she should have asked herself, but it didn’t matter, as it had been done.

“Do you have any additional questions?” Fyodor said.

“I think that covers it,” Sandra said, and started to rise. But then she hesitated. Settling back onto her chair, she said, “There is one other thing.”

“Please,” Fyodor said agreeably. He even managed an unctuous smile.

Similar to what she had said to the two medical students, Sandra then went on to describe the jump, or blink, or blip—she really didn’t know how best to describe it to these professionals—that she had seen on the monitor when the surgeon had begun drilling into the
tibia. As she spoke, she sensed from his expression that Fyodor was disbelieving that such a thing could occur. In response, Sandra said that it could actually be seen on the machine-generated anesthesia record. “It is a very small change, but it is visible. If you bring up the Vandermeer anesthesia record on your terminal, I’ll show you.”

After a quick glance between Fyodor and Misha, which included a nod from Fyodor, Misha went to the computer monitor on Fyodor’s desk, brought up the record, and then stepped aside. Sandra then took over. As she had done when she’d been with the medical students, she zoomed in on the tracing of the vital signs. She pointed to the place fifty-two minutes into the case, where all the tracings notched upward. “There,” she said, pointing. “See the vertical jump? And when it happened, the monitor blinked, which caught my attention. It made me worry I was about to lose my feeds.”

“Interesting,” Fyodor said, leaning closer to the monitor. “I see what you mean. What do you think it is?”

“You are asking me?” Sandra questioned. “I don’t know. You people are the experts. To be truthful, I’m not all that knowledgeable about electronics. I came down here to ask you.”

Fyodor sat back and looked up at Misha for a beat. “I don’t know what it could be, but it can’t be anything significant.” Then his attention went back to the monitor. “The tracings all look totally normal before and after. What do you think, Misha?” Fyodor leaned back and caught Sandra’s surprised expression and explained, “I might be the department supervisor, but Misha is our key anesthesia machine technician. We brought him from Russia specifically to work on the anesthesia machines. He did a lot of the original coding for the model that we have here at the Mason-Dixon. He is what you say in English the go-to guy.”

Sandra was impressed by this news since she thought so highly of the anesthesia machine, although it still didn’t influence her negative visceral reaction to the man.

Misha made it a point to bend over and study the image on the monitor.

“I know it is small change,” she went on to explain, “but I had never seen it before, and since the case turned out to have such a terrible outcome, I just want to make sure it has no significance. I mean, if the patient had awakened after the case, I might not even have remembered it happened. Well, maybe that’s not totally true, since it did scare me about the possibility of losing my electronic monitoring.”

“It’s not important,” Misha said. He stood back up.

“But what was it?” Sandra persisted.

“It’s just a frame offset,” Misha said. “It’s nothing. It could happen from a number of things, like . . .” He gestured with his hands in the air, struggling to express himself with his English.

“Like what?” Sandra asked.

“What you have to remember is that the machine’s computer is constantly compressing data,” Fyodor said, coming to Misha’s aid. “You have no idea how much data is being constantly generated. So seeing little changes on a monitor is not surprising. There can be blips from hardware malfunction, like one of the hundreds of capacitors prematurely discharging, or from a software problem confronting momentary input overload or even from just too many applications running at the same time.”

Sandra nodded as if she understood. She didn’t, but it was clear they did not think a frame offset had any real significance. She was about to thank them and leave when the two men suddenly launched into an animated and spirited conversation in Russian. For Sandra it was like momentarily watching a Ping-Pong game up close, her eyes darting from one man to the other. Then, as suddenly as the heated discussion had started, it stopped.

Fyodor smiled. “Sorry, it is rude for us to speak Russian. We disagree on a small issue. No matter. The important point is that
whatever caused this small frame offset you noticed certainly didn’t affect the anesthesia machine’s function.” He smiled again. “Is there anything else we can help you with, Doctor?”

“That’s it for the moment,” Sandra said. She stood up. “Thank you for your time.”

“We are here to serve,” Fyodor said. “Anytime you have a question, please come down or call. As you know, we have technicians available twenty-four hours, seven days a week.”

As she left the supervisor’s office, Sandra fully expected Misha to follow her. She had been mildly concerned about getting away from him, the way he had glommed onto her when she had first arrived. To her surprise and relief, he stayed inside the office with Fyodor.

Heading back to the elevators, Sandra thought she would go back up to the OR and see what she had been assigned for the following morning. If any of them were inpatients, she would go check them out. She would review the nascent electronic medical record for the ones having same-day surgery to get an idea of what the day would be like. The episode with Carl was making her more compulsive than ever. When she finished all that, she would head for home.

Tuesday, April 7, 2:41
P.M.

F
or a few minutes after Dr. Sandra Wykoff had left, silence reigned in the Clinical Engineering supervisor’s office. The only noise came from out in the service area and was the muted whine of various electric tools combined with a hint of classical symphonic music. The two Russian expats regarded each other while immersed in their own thoughts. Both were not happy, but for slightly different reasons.

Fyodor Rozovsky had been in Charleston for several years before he had recruited Misha Zotov. The men had known each other since childhood, having both grown up in Saint Petersburg. Also, both of them had attended the Moscow Institute of Physics and Technology. Fyodor had been brought to America almost a decade earlier, when Sidereal Pharmaceuticals had agreed to fund the Shapiro Institute. With Fyodor’s knowledge of computer coding and robotics, he had been clearly essential to the project’s success. His contributions had been such that after the Shapiro was successfully up and
running, Middleton Healthcare happily offered him the opportunity to run Clinical Engineering for the entire medical center. The company felt that progressive automation was key for hospital-based medicine.

“I don’t like this,” Fyodor said. He was now speaking Russian, and his irritation was apparent. “Sergei Polushin is going to be as angry as a bear if this blip becomes a subject of general discussion in the Anesthesia Department.”

Sergei Polushin, a financial genius, was reputed to be the closest confidant to Boris Rusnak, the billionaire Russian oligarch who had created Sidereal Pharmaceuticals. Living in Geneva, Rusnak, with Sergei’s help, had aggressively merged a number of small drug firms by a series of rapid, hostile takeovers to build one of the world’s largest. More important, the company was poised to become the dominant player in the newest pharmaceutical gold mine: making and marketing biologics, or drugs made by living systems, not by chemistry. Sergei Polushin had been the force behind the Shapiro Institute, and continued to treat it as his personal fiefdom.

“I need to have a frank discussion with my team of programmers,” Misha said. Gone was any hint of the fawning facade he presented to Sandra. He was clearly as angry as Fyodor. “A frame offset like that is just sloppy programming. The trouble is I didn’t see it myself.”

“I don’t need to tell you, but Sergei will undoubtedly hold you responsible if this thing causes trouble.”

“You don’t need to tell me,” Misha said. “I will see that it is eliminated immediately. When is the next case scheduled?”

“Not until next week, so you have plenty of time. But it is important to get it fixed. The schedule is to do a case a week in all the Middleton Healthcare hospitals. There cannot be any bugs. Is it possible this same phenomena occurred with either of the two previous test cases?”

“I don’t know,” Misha said. “Let’s check the pilot case!” He grabbed a chair, sat, and used the terminal on Fyodor’s desk to pull up Ashanti Davis’s anesthesia record. When it was on the monitor, he magnified the central portion just as Sandra had done with Vandermeer’s.

“There it is,” Fyodor said. “That’s not good. Let’s check Morrison.”

Misha quickly did the same with Morrison’s anesthesia record as he had done with Davis’s. “Shit! There it is with Morrison as well. Sorry about that!”

“Fix it!” Fyodor said gruffly.

Misha exited the screen. “Luckily, no one has noticed the offset on either of the previous test cases.”

“Are you suggesting that it not be fixed?”

“I will see that it is fixed today. My point is questioning whether we should go back and try to eliminate the offset in all three documents.”

“Can you do that?”

Misha shrugged. “Actually, I don’t know. Probably, but then again we could make it worse, meaning leaving a fingerprint that it had been altered after the fact. I could have someone try before actually executing and show you in an hour or so what it would look like.”

“All right. But, most important, fix the bug itself.”

“Certainly. But that leaves the issue about Dr. Wykoff and whether she is likely to enlist the help of anyone else in explaining the frame offset.”

“That question has occurred to me, too. We know that both the chief of anesthesia and the hospital lawyer have urged the parties involved against loose talk. Talking about even a minor blip in the vital sign tracings would certainly qualify as loose talk.”

“That is true, but is it worth the risk? I’m afraid she has become a major liability. It seems to me that this is a circumstance where
the services of Darko and Leonid are called for and sooner rather than later.”

Both Fyodor and Misha had met Darko Lebedev and Leonid Shubin. They knew the two had been members of the Soviet Special Forces and had served a number of years in Chechnya, tracking down and eliminating people Moscow deemed terrorists. They knew that Boris Rusnak had hired the two men away from the army early in Boris’s meteoric rise in the rough-and-tumble business world of post-Soviet Russia, where people of Darko and Leonid’s abilities and mind-set were a necessity. Fyodor and Misha were well aware that both killers had seen a lot of action. They also knew that Sergei Polushin had sent them to Charleston as a potential resource to support Sidereal’s considerable US investment.

Easing back in his chair, Fyodor let his eyes roam up to the ceiling and allowed his mind to wander. Misha had a point, and a good one. Dr. Sandra Wykoff represented a very weak link in what was otherwise a strong chain. She could set the program back, maybe even stop it for a time. It would be irresponsible for Fyodor to let such a risk continue, especially when it could easily be eliminated. Wykoff had been selected as one of the test cases specifically because she was a loner, as were the two other anesthesiologists that had been chosen before her. Misha had been tasked to try to get close to her, although that tactic had fallen flat. They had used Russian call girls with the other two male anesthesiologists to keep tabs on them, and that had worked well. But Sandra Wykoff had been different and now presented a real problem. There was no way to find out what she was thinking.

Fyodor tipped forward in his chair. He’d made up his mind. “I don’t like this woman,” he said.

“She is a high-and-mighty bitch,” Misha agreed. “I tried to be nice to her. Trust me! She thinks she is something special. She is going to be trouble.”

“All right,” Fyodor said. “She’s got to be taken care of. Do you want to talk with Darko and Leonid, or should I? I know they have been eager to be useful.”

“It will be my pleasure,” Misha said, getting to his feet. “I’ll call Darko as soon as I get my team of programmers busy.”

“Keep me informed,” Fyodor said.

“I will,” Misha promised.

Tuesday, April 7, 3:04
P.M.

B
enton was ushered into Josh’s posh digs by one of the president’s aides. It was a corner office looking out onto the manicured hospital grounds. It was as large and as well appointed as any Fortune 500 CEO’s and befitting Josh’s role as both president of the Mason-Dixon Medical Center and chairman of the board of Middleton Healthcare. Benton couldn’t help but be jealous. Josh was a new kind of doctor. He had gotten an MBA at the same time he’d gotten his MD to take advantage of health care’s being the biggest business in the United States, at $4 trillion a year and counting.

Benton also knew that Josh was holding down an annual salary of over $4 million, with hefty stock options to boot. Under his tenure, Middleton Healthcare had grown from twenty-four hospitals in the Southeast to thirty-two spread throughout the country. Equally as impressive, he had forged the lucrative alliance with Sidereal Pharmaceuticals. As a department head, Benton was aware that significant cash infusions from Sidereal were coming into Middleton’s coffers every month to bolster infrastructure.

From Benton’s perspective, Josh Feinberg didn’t look the part of
an accomplished CEO or even a doctor. He was a slight man with an intense, gaunt face and shifty eyes more suggestive of a crooked used-car salesman than an accomplished hospital administrator. Although his suits were probably expensive, they hung on his bony frame like clothes on a wire hanger. But despite having less than a commanding appearance, Benton knew that Josh was a superb businessman, with his MBA from Benton’s Ivy League alma mater.

Before being recruited to take over Middleton Healthcare, Josh Feinberg had a stellar record of founding and managing a highly successful health-care consulting company called Feinberg Associates. Although functioning behind the scenes, this company had been responsible for a slew of medical products and procedures ranging from medical software to teeth-whitening strips. The source of its success was that it employed many hundreds of Russian PhD scientists who’d found themselves out of work after the dissolution of the Soviet Union.

Once at Middleton Healthcare, Benton was well aware that Feinberg had not only expanded the company but had also spearheaded the lucrative Sidereal Pharmaceutical connection. In the process, Feinberg had fostered a personal relationship with the otherwise reclusive billionaire Boris Rusnak. From the Russian’s reputation, Josh’s connection with the man might have been his biggest coup of all.

Josh offered Benton one of the chairs facing his massive desk, but Benton declined, saying he’d rather stand because he had to get back up to the OR and what he had to say wasn’t going to take much of Josh’s time.

“Have you spoken with Bob Hartley?” Benton asked, as a way to begin.

“No. Should I have?”

“No matter,” Benton said. “Let me clue you in.” He then had the same conversation he’d had with Hartley. Like Hartley, Josh took the story seriously, writing down the names of the medical students
as Benton talked. The longest part of the conversation concerned Dr. Sandra Wykoff and what to do about her. Rhodes said she was a good anesthesiologist and committed to her work but somewhat of a loner and not always a team player. He admitted he didn’t have a full understanding of her.

“And you say Hartley will be getting in touch with me?” Josh asked.

“That’s what he said.”

“Good. About the two medical students looking into hospital-acquired morbidity: I’m sure that can be nipped in the bud. I’ll talk with the dean to make sure they toe the line. But on the off chance one or both don’t and persist with their inquiries, I want you to personally let me know immediately.”

“You mean if they contact Dr. Wykoff again?”

“Precisely. Whether they contact Dr. Wykoff or one of the other involved anesthesiologists, give me a heads-up. They could be a big problem, especially in the context of investigating hospital-acquired morbidity. We don’t want to stimulate any kind of unanticipated inspection by the Joint Commission with the way they are already busting our balls about access to the Shapiro Institute.”

“How will I get in touch with you if it’s off hours?”

“Text me!” Josh said. “I’ll have one of my aides give you my personal mobile number.”

“You got it,” Benton said. He felt flattered that Josh would be willing to give him his mobile number, but he wasn’t totally surprised. Josh had specifically and heavily recruited him five years earlier, and they had a somewhat social relationship.

“I certainly will take it from here. Thank you, Doctor.” As if by magic, the door to Josh’s office swung open. Standing on the threshold was Josh’s closest aide, Fletcher Jefferson. Josh gestured toward the man to let Benton know the meeting was over.

“You’re welcome,” Benton said, a bit surprised at being dismissed so summarily. If he hadn’t been flattered by the course of the
meeting, he would have felt slighted. As he passed out of the room, Mr. Jefferson gave Benton a piece of paper. On it was Josh’s mobile number.

•   •   •

F
or several minutes after Dr. Rhodes had left, Feinberg played absentmindedly with his computer mouse, moving it in small circles to watch the cursor dance on his monitor. He hated picayune annoyances requiring his attention in the middle of big, momentous events. This current issue involving a spinster woman anesthesiologist and a couple of greenhorn medical students was a prime example.

Josh and Boris Rusnak currently were orchestrating a complete revolution in the pharmaceutical industry by modernizing and significantly improving the manufacture of biologics, and he needed to be on the top of his game. Biologics were where the industry was heading, thanks to the prices they were commanding and thanks to Middleton Healthcare’s alliance with Sidereal Pharmaceuticals. Since he and his team had forged this marriage, he was positioned at the very vortex of the change and stood to be rewarded beyond his wildest dreams. Within the hour he expected a conference call from Boris arranged by his chief aide, Sergei Polushin, and Josh already knew what was going to be discussed. They were going to propose that Sidereal double its projected antibody production by utilizing all thirty-plus Middleton Healthcare hospitals rather than the five that had been originally proposed. Such a situation would be huge and would essentially guarantee a merger between Sidereal and Middleton. With that kind of dependence, there was no way that Sidereal would allow Middleton Healthcare to go off on its own, as it would undoubtedly be courted by other multinational drug firms.

Pressing a button under the lip of his desk, the same button he’d pressed to end the meeting with Benton Rhodes, Josh waited for
Fletcher to reappear. Seconds later he handed Fletcher the paper on which he had written the names of the two medical students.

“I want a rapid rundown on these kids,” Josh said. “I want to know where they live, where they are from, their family situations, and their significant others. Later I want details, but for now, the basics. Go!”

While he waited, Josh went back to fidgeting with his cursor. He knew that the upcoming call from Geneva might be the defining event in his life. Yet he wasn’t nervous, because he was prepared. Although he thought he knew what the agenda was going to be, he was ready to field a wide variety of curveballs. What he counted on was that Sidereal needed Middleton, and not vice versa.

After only five minutes, a muffled knock preceded Fletcher’s reappearance. He came directly to the front of Josh’s desk and put down a single sheet of paper. On it each student had a paragraph. Josh snapped up the paper and read it rapidly.

“Good,” Josh said, looking it over. “Perfect. They are both living in the dorm: that’s good. Both accomplished students: that’s good, since both have a lot to lose. Both on full scholarships: that’s helpful, too, as they probably are grateful. And they are good friends, which makes dealing with them easier: convince one, and that one would surely convince the other.”

Josh looked up. “Well done. Now, get the details!”

As Fletcher turned to leave, Josh reached for his phone. He knew that the best administrators knew how to delegate, and that was exactly what he was going to do. Thanks to Sergei Polushin, there was a resource to handle problems raised by the likes of Robert Hurley and now Sandra Wykoff and a couple of medical students. With a touch of a button Josh was on a direct line with Fyodor Rozovsky.

“There are a couple of other problems,” Josh said with no preamble, not even identifying himself. Names were not needed, as they knew each other’s voice, as the “project” required frequent
contact, and they talked rather than e-mailed or texted to eliminate any potential paper trail. “The anesthesiologist, Sandra Wykoff, has become a true threat.”

“We are already aware,” Fyodor said. “She just visited us here in the service center to ask probing questions. It has already been decided, and an appropriate call has already been made. The problem will be solved tonight.”

Josh was taken aback that they were a step ahead but pleased. “I commend your efficiency.”

“We have only the best and most experienced personnel,” Fyodor said with pride.

“I guess commendation is in order for the solution to the previous Hurley threat.”

“Thank you. There were no problems.”

“One other thing while I have you on the phone. There is another minor problem that might be best handled by your experienced personnel. I’m sorry that all this is happening at the same time.”

“We are here to deal with problems. No need for an apology. What minor problem are you referring to?”

“There are now a couple of medical students, a male and a female, who are close friends. They have made a nuisance of themselves talking with Sandra Wykoff about the Vandermeer case. The motivation is because of a misplaced interest in the issue of hospital-acquired morbidity. This has to stop! I’ll try to address it through the dean of the school, but I thought you should be aware. Maybe a warning to one of them might be in order, although I will leave that up to you. I’ll send down the names and the particulars.”

“We will be looking for it. In the meantime, rest assured that the anesthesiologist will be taken care of. As for the students, we’ll have someone talk convincingly to the female. In Russia we found that was the best course of action with couples.”

“I’ll trust your judgment,” Josh said simply before disconnecting the line. He was pleased and relieved to have the issue about the
rogue anesthesiologist already behind him. It was easy to delegate when one had the right people. With the most important part of this new problem already solved, he placed a call to the dean of the medical school, Dr. Janet English, about the rogue students. This conversation was even shorter and to the point. “Talk to them as soon as you can,” Josh said at the end. His mind was already back to anticipating the imminent conference call from Geneva.

“I will contact them immediately,” Dr. English said. “Consider it done.”